Every finding on record at Olney Rehabilitation and Care Center

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The wooden cabinet doors beneath the handwashing sink did not close completely. 2. The high-temperature dish machine did not work properly and was not being used. 3. The dietary staff were manually washing the resident use eating utensils, beverage glasses, coffee cups, the pots, pans, mixing bowls, cooking utensils and serving utensils in a two-compartment sink.4. The dietary staff did not document water temperatures and bleach sanitizer levels for the two-compartment sink.5. Floor tiles were missing beneath the high temperature dish machine.6. Wooden shelf units and cabinet had scraped surfaces and peeling paint with the porous wooden surfaces exposed and not sealed.7. Shelf liner was used to cover wooden shelves in the paper supply room and the shelves were soiled with food crumbs and dust beneath the shelf liner.8. Opened packages of dry foods were not stored in resealable bags or containers and were not labeled and dated when opened.9. The top exterior surface of the ice maker was soiled with a thick layer of dust build-up. The facility's failure placed residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.The findings included: Observations and interviews on 12/09/25, between 9:45 AM and 10:10 AM, during the initial tour of the facility kitchen, revealed the following:- The liquid soap dispenser mounted on the wall near the hand washing sink; the dispenser was empty and a bottle with dish detergent was on the counter next to the sink to use for hand washing.- The wooden cabinet doors beneath the sink and counter did not close completely.- The Dietary Manager stated a new high temperature dish machine was delivered about 2 weeks ago and was installed. She stated the back two legs of the dish machine were removed by the Maintenance Director. The back of the dish machine was observed resting on wooden blocks. The Dietary Manager stated the dish machine was not a good fit in the space between the stainless steel counters. - The Dietary Manager stated the dish machine was connected but it kept throwing the breaker when operated. She stated the dietary staff were told not to use it until an electrician could come to the facility and fix the breaker.- The Dietary Manager stated the residents were being served meals on paper (disposable) plates and bowls. She stated the residents were using the stainless steel silverware, beverage glasses, and coffee cups. She stated the dietary staff were using a two-compartment sink to wash the silverware, eating utensils, beverage glasses, coffee cups, pots, pans, serving utensils, and mixing bowls. The Dietary Manager stated detergent and bleach were added to the water in the first sink compartment and bleach was added to the water in the second sink compartment to sanitize. She stated there was not a sink used for clear rinse water. - The Dietary Manager stated she was not keeping a log of the two compartment sink water temperatures or bleach sanitizer level. - The floor tiles had been removed and were missing in the area beneath the dish machine and the concrete floor was exposed.- The wooden shelves and cabinets had scraped/peeling paint throughout the kitchen.- The paper supply closet had 9 wooden shelves covered with a thick textured shelf liner; the shelves were soiled with dust and food crumbs beneath the shelf liner; a plastic container with dry cereal, labeled as corn flakes was dated 9/02/25. The Dietary Manager stated the cereal was a staff member's and only 1 resident ate cold cereal and he had his own. - The wooden shelf unit on the wall to the left of the steam table had shelf liner covering the painted surface and contained inverted plastic bowls.- The old gas steamtable no longer worked and was located against the wall in the corner. The Dietary Manager stated she wished it would be removed. Observation and interview on 12/09/2025 at 10:12 AM, during observation of the Dietary Manager's office located in the East Hall in room [ROOM NUMBER], revealed the following: - The office was used for non-perishable food storage and contained a commercial refrigerator unit, and 2 wire rack shelf units which contained dry food items.- The shelves held an open bag with bread crumbs dated 8/29/25 that had been twisted to close, an open bag with small elbow macaroni that was not dated and had been knotted/tied to close, an open bag with small egg noodles dated 10/24/25 twisted to close, refried pinto beans in a resealable plastic bag that was not labeled and dated when opened, a 5 pound bag with white cake mix in a resealable bag dated 8/05. The Dietary Manager stated she hoped it was 2025 and not 2005. She stated she would throw the cake mix and pinto beans away.- A commercial refrigerator unit was against the wall behind the Dietary Manager's desk. The refrigerator was non-working and was used to store paper plates, cups, and plastic cup lids. The Dietary Manager stated she wished it would be removed from the room. Observation on 12/09/2025 at 10:28 AM revealed an ice maker in the hallway outside the door to the kitchen, located to the left of the nurse's station. The exterior top surface of the ice machine was soiled with a thick layer of dust. In an interview on 12/09/2025 at 11:30 AM, the DON stated she was the facility's Infection Preventionist. The ADON stated the residents had received influenza and pneumococcal vaccinations during September and October 2025. The ADON stated she would provide the infection control log for review. The ADON stated the facility had not had any outbreaks of any types of virus or infections, including respiratory or gastrointestinal. Record review of the facility's infection control tracking log indicated no infections related to gastrointestinal upset [nausea, vomiting, diarrhea] were documented during the months of November and December 2025. There was no documented evidence of indicators or symptoms of foodborne illness. During an observation and interview on 12/09/2025 at 3:18 PM, the Dietary Manager indicated the large tub purchased at the local hardware store. The label indicated a 27-gallon capacity. The tub was positioned on the stainless steel counter. The Dietary Manager provided a bottle with quaternary sanitizer. The label directed to use 1 ounce of sanitizer to 4 gallons of water. The recommended sanitizer level was 200 - 400 ppm. The Dietary Manager stated she mixed 1 ounce with 4 gallons of room temperature/faucet water. She measured the sanitizer/water solution with a test strip at a level of 200 ppm. The tub was observed to be large enough to hold rectangular sheet pans.[An online search for this product indicated the recommended water temperature was 75 degree F to 120 degrees F.] In an interview on 12/10/2025 at 1:20 PM, the Maintenance Director stated the electrician came to the facility after the lunch meal was served. He stated the electrician was going to replace the 20 amp breaker for the dish machine and he would go from there. In an interview on 12/11/2025 at 12:10 PM, the Dietary Manager stated the breaker for the dish machine had been changed yesterday (12/10/2025) but dish machine was still not running right and the staff were not using it. She stated the technician from the new chemical supply and service company would be at the facility next Monday or Tuesday (12/15/2025 or 12/16/2025) to work on the dish machine. The Dietary Manager stated the staff started using paper products the same day the new dish machine was installed, as it did not run right and tripped the breaker. She stated they used up the supply of paper products that was in storage and they bought paper products at the local grocery store until paper products could be ordered. [The new dish machine was installed 10/09/2025.] In an interview on 12/11/2025 at 5:49 PM, the VPCO stated a possible negative outcome from not having an operational dish washer and not utilizing a proper manual dishwashing procedure with a 3-compartment sink could be the spread of infection and possible foodborne illness. Review of the facility policy and procedure for Sanitation Inspection, dated 2025, indicated [in part]:Policy:It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.Policy Explanation and Compliance Guidelines:1. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.Review of the facility policy and procedure for Manual Warewashing - 3 Compartment Sink, dated as reviewed/revised 12/11/2025, indicated [in part]:Policy:2. To prevent the spread of bacteria that may cause food borne illness, this facility washes, rinses, and sanitizes pots, pans, and other utensils using a 3 compartment sink in accordance with current standards for food safety. The Food and Drug Administration Food Code 2022 specified [in part]:Chapter 3 Food3-202.15 Package Integrity.FOOD packages shall be in good condition and protect the integrity of thecontents so that the FOOD is not exposed to ADULTERATION or potentialcontaminants. Chapter 4 Equipment, Utensils, and Linens4-602.13 Nonfood-Contact Surfaces.The presence of food debris or dirt on nonfood contact surfaces may provide a suitableenvironment for the growth of microorganisms which employees may inadvertentlytransfer to food. If these areas are not kept clean, they may also provide harborage forinsects, rodents, and other pests.

Based on observation, interview, and record review, the facility failed to ensure the maintenance of mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that:The low temperature dish machine was not operating and was not being used to wash and sanitize the resident use eating utensils, beverage glasses, coffee cups, and the food preparation pots, pans, mixing bowls, cooking utensils, and serving utensils. This failure placed the residents at risk for foodborne illness and a decline in health status from being served food that had been prepared with pans and utensils that had not been properly sanitized. The findings included: Observation on 12/09/2025 at 9:50 AM revealed a high temperature dish machine was located in the facility kitchen. The manufacturer recommendations were for minimum water temperatures at 160 degrees F for washing and at 180 degrees F for rinsing. The dish machine was not in use at the time of the observation. In an interview on 12/09/2025 at 9:50 AM, the Dietary Manager stated a new high temperature dish machine was delivered about 2 weeks ago and was installed. She stated the back two legs of the dish machine were removed by the Maintenance Director. The back of the dish machine was observed resting on wooden blocks. The Dietary Manager stated the dish machine was not a good fit in the space between the stainless steel counters. The Dietary Manager stated the dish machine was connected but it kept throwing the breaker when operated. She stated the dietary staff were told not to use it until an electrician could come to the facility and fix the breaker. The Dietary Manager stated the residents were being served meals on paper (disposable) plates and bowls. She stated the residents were using the stainless steel silverware, beverage glasses, and coffee cups. She stated the dietary staff were using a two-compartment sink to wash the silverware, eating utensils, beverage glasses, coffee cups, pots, pans, serving utensils, and mixing bowls. The Dietary Manager stated detergent and bleach were added to the water in the first sink compartment and bleach was added to the water in the second sink compartment to sanitize. She stated there was not a sink used for clear rinse water. The Dietary Manager stated she was not keeping a log of the two compartment sink water temperatures or bleach sanitizer level. In an interview on 12/09/2025 at 1:46 PM, the facility Maintenance Director stated he had worked in this facility for the past 11 years. He stated the new management company took over on 12/01/2025. The Maintenance Director stated the old dish machine went out during September or October 2025. He stated the pump for the chemicals went out and they could not get parts for it. He stated the Executive from the facility's prior management company got the new dish machine. The Maintenance Director stated he did not know where the Executive got it or where it came from. He stated it was delivered during mid-November. The Maintenance Director stated it was new and wrapped in plastic. He stated the Maintenance Director from the prior sister facility in located in another town came and together they took the new dish machine out of the box and put it together and installed it in the kitchen. He stated they could not program it. The Maintenance Director stated the new dish machine tripped the breaker every time it was used. He stated the back legs had been removed and placed on wooden blocks in an attempt to move the dish machine back closer to the wall. He stated the plumbing was on the outside of the walls and the drain line ran along the base of the wall and prevented the dish machine from being pushed back closer to the wall. The Maintenance Director stated the facility would have a new chemical supply and service company for the dish machine, laundry, and housekeeping. He stated technician from the new chemical supply and service company would be able to program the dish machine and to determine the voltage for the machine to make recommendations to an electrician and plumber. He stated the facility's new management company was working on the contract with the chemical supply and service company. The Maintenance Director stated there had not been any viruses or bugs that moved through the facility residents - no diarrhea, no vomiting. In an interview and observation on 12/09/2025 at 2:29 PM, the Dietary Manager stated she was not present when the new dish machine was installed. The Dietary Manager stated the new dish machine kept throwing the breaker and she was told not to use it. The Dietary Manager inquired if a large bin could be used as a third compartment to fill with water and quaternary sanitizer. She stated she had quaternary sanitizer and the test strips for it and stated the test strips were delivered with the food order today. The Dietary Manager stated quaternary sanitizer did not have to be used in hot water, it could be in cool water. In an interview on 12/09/2025 at 3:10 PM, the Maintenance Director stated an electrician would be at the facility in the morning and would assess whether the breaker was bad or if the entire breaker box needed to be replaced. He stated the kitchen had its own breaker box, located on the wall between the refrigerator and freezer units. The Maintenance Director stated the new chemical supply and service company was contacted and they said the dish machine was good and to have the electrician evaluate the voltage on the breaker box. In an interview on 12/10/2025 at 1:20 PM, the Maintenance Director stated the electrician came to the facility after the lunch meal was served. He stated the electrician was going to replace the 20 amp breaker for the dish machine and they would go from there. During an interview and record review on 12/10/2025 at 1:50 PM, the Business Office Manager provided copies of printed email messages regarding the order for the dish machine. The email message dated 9/26/2025 documented the order was from a restaurant supply vendor and would be delivered by freight shipment. The Business Office Manager wrote a notation on the copy of the email that documented the dish machine was delivered to the facility on [DATE]. The Business Office Manager showed a text message saved on her cell phone from the Maintenance Director from a sister facility who had come to the facility to assist the Maintenance Director with installing the new dish machine. The text message from the Maintenance Director to the Business Office Manager was dated 10/09/2025 and specified they had wired the dish washer machine. The Business Office Manager stated the dish machine was installed 10/09/2025, the day after it was delivered. In an interview on 12/11/2025 at 5:49 PM, the VPCO stated a possible negative outcome from not having an operational dish washer and not utilizing a proper manual dishwashing procedure with a 3-compartment sink could be the spread of infection and possible foodborne illness. Review of the facility's policy and procedure for Mechanical Cleaning and Sanitizing of Utensils and Portable Equipment, dated 10/01/2018, indicated [in part]: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for mechanical cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards.Procedure:1. Use only an approved dish machine that is properly installed and maintained. Operate the dish machine as instructed in the manufacturer's directions. Schedule and complete regular maintenance inspections.

Based on interviews and record review, the facility failed to ensure 1 Quarterly MDS (Minimum data set) Assessment and 1 Significant Change MDS Assessment was encoded, accurate, complete, and electronically transmitted to the CMS (Center for Medicare & Medicaid Services) system for 2 of 6 residents (Resident #1 and Resident #12) whose MDS records were reviewed. The facility did not ensure the Quarterly MDS assessment was completed and electronically transmitted as required for Resident #1. The facility did not ensure the Significant Change MDS assessment was completed and electronically transmitted as required for Resident #12. These deficient practices placed residents at risk for not being assessed for current functional status and changes in condition to develop or revise a plan of care to meet their needs.The findings included: 1. Record review of Resident #1's face sheet accessed on 12/11/2025 revealed the resident was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included Type 2 diabetes (problem with the way the body regulates and uses blood sugar), gout (painful inflammatory arthritis from excess uric acid), unspecified dementia (memory problem not yet identified), hypertension (high blood pressure), and left leg amputation (removal). Record review of Resident #1's MDS assessments revealed a Quarterly assessment dated [DATE] with a status of Export Ready and was never transmitted to CMS. Record review of Resident #1's EHR (electronic health record) revealed a progress note signed by the SW (Social Worker) dated 11/10/2025 indicating there was a meeting with the resident to complete the Quarterly assessment, the resident scored a 12 on the BIMS (Brief Interview of Mental Status), and monitoring would continue as part of the plan of care. 2. Record review of Resident #12's face sheet accessed on 12/11/2025 revealed the resident was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease ( a progressive lung disease causing airflow obstruction), unspecified dementia (memory problem not yet identified), and hypertension (high blood pressure). Record review of Resident #12's MDS assessments revealed a Significant Change assessment dated [DATE] with a status of Export Ready and was never transmitted to CMS. Record review of Resident #1's EMR revealed a progress note signed by the SW dated 11/19/2025 indicating the resident's chart was audited and was noted that resident's preferences were not included in the care plan and Power of Attorney paperwork was missing. During an interview on 12/11/2025 at 3:00pm with VPCO (Vice President of Clinical Operations) stated the nurse that now completes the MDS assessments is the VPCR (Vice President of Clinical Reimbursements) and has been working through them since the new management company took over on 11/19/2025. The VPCO stated it had been a challenge as the outgoing administrator and owner made if very difficult for them to get access to the SIMPLE website (that was used for inputting MDS assessments). She stated now the VPCR was having to log into both systems to get the assessments up to date and transmit them to CMS. The VPCO stated it was her expectation that all MDS assessments were completed accurately and according to the RAI (resident assessment instrument) manual. Stated these assessments were very important and it shows the true picture of the resident to create a person-centered care plan that would assist staff in providing the best care possible for the resident, further stating that when completing an admission assessment it must be signed and submitted to CMS within 14 days. The VPCO then stated an adverse outcome would be the staff not knowing or understanding how to take care of a resident making the assessments very important. During an interview on 12/11/2025 at 4:16pm with VPCR, she stated that she had 20 years of experience with MDS Assessments. She stated the expectation that the assessments, admission or significant change, were completed and showed a full picture of the residents to create a care plan that would assist the staff in providing the best care for the residents. She then stated the assessments must be submitted to CMS with 14 days of admission and an adverse outcome would be the care plan doesn't get completed and then it doesn't show the staff how to take care of the residents. During an interview on 12/11/2025 at 4:45pm with ADMN (administrator) stated he had only been at this facility as the interim administrator for 2 weeks. He stated from what he knows, the MDS assessments do have a time limit on how long they have to submit them to Medicare but he wasn't completely sure on dates. The ADMN acknowledged the 2 MDS assessments for Resident #1 and #12 should have been submitted way before that day. He further stated it was important to complete all assessments in a timely manner, and he would be following up on this to make sure it was taken care of. Record review of the policy named MDS 3.0 Completion not dated revealed [in part]:Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines:#7. Transmission Requirements:a. All assessments shall be transmitted to designated CMS system (iQIES) within 14 days of completion.b. Each assessment must be accepted into the system, as verified by validation reports. Record review of the CMS RAI 3.0 Manual Version 1.20.1 last revised October 2025 revealed [in part]: Encoding data: - For a comprehensive assessment (Admission, Annual, Significant Change in Status, and Significant Correction to Prior Comprehensive), encoding must occur within 7 days after the Care Plan Completion Date (V0200C2 + 7 days). -For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date. Transmitting data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on interview and record review, the facility failed to ensure assessments accurately reflected the health status for 2 of 14 residents (Residents #13 and #27) whose MDS assessments were reviewed, in that:1. Resident #13 had a physician order for insulin to be administered one time weekly on Monday per a sliding scale. Her MDS documented she received insulin injections daily.2. Resident #27 had a physician order for an antiplatelet medication. Her MDS assessments documented she received an anticoagulant medication. This failure placed residents at risk for not receiving care and services to meet their physical needs.The findings included: Review of the Resident #13's admission Record, dated 12/11/2025, documented a [AGE] year-old-female admitted to the facility on [DATE]. The record documented the resident's diagnoses included type 2 diabetes mellitus (a chronic condition when the body cannot use insulin properly resulting in high blood sugar levels). Review of Resident #13's Order Summary Report documented an order dated 1/22/2022 for NovoLIN R FlexPen ReliOn Solution Pen-injector 100 UNIT/ML (Insulin Regular Human) - Inject subcutaneously one time a day every Monday for type 2 diabetes mellitus per sliding scale. Review of Resident #13's Medication Administration Record, dated August 2025, documented FSBS levels every Monday and documented no sliding scale Novolin insulin was administered. Review of Resident #13's Quarterly MDS assessment, dated 9/01/2025, documented the resident received insulin injections daily. Review of Resident #27's admission Record, dated 12/11/2025, documented a [AGE] year-old female admitted to the facility on [DATE] with a primary admitting diagnosis of atrial fibrillation (irregular heartbeat). Review of Resident #27's Order Summary Report documented an order dated 5/22/2025 for Clopidogrel 75 mg by mouth one time daily for atrial fibrillation (Plavix - antiplatelet medication). Review of Resident #27's Quarterly MDS assessment, dated 6/04/2025, documented the resident received an anticoagulant medication. In an interview on 12/11/2025 at 9:15 AM, the RN VPCO stated the facility did have a policy for completing MDS assessments and also followed the guidelines of the RAI manual. She stated the VPCR had been completing the residents' MDS assessments since the change in management companies on 11/19/2025. In an interview on 12/11/2025 at 9:17 AM, the DON stated the prior MDS Coordinator was a nurse who resided in another city and had completed the residents' MDS assessments remotely. During an interview and record reviews on 12/11/2025 at 5:05 PM, the VPCR stated she had started reviewing and completing MDS assessments for residents in the facility on 11/19/2025. She stated the Regional MDS Coordinator had been helping with the MDS assessments. The VPCR reviewed Resident #13's order for sliding scale Novolin insulin to be administered one time weekly on Monday, and reviewed the resident's MDS assessment dated [DATE]. She stated the insulin injection administered daily for 7 days was inaccurately documented on the MDS assessment. The VPCR reviewed Resident #27's order for Clopidogrel and the resident's MDS assessment dated [DATE]. She stated the Clopidogrel was an antiplatelet medication and had been inaccurately coded as an anticoagulant on the MDS assessment. The VPCR stated an expected negative outcome from MDS assessments not being accurately completed would be the inability to develop a care plan for the staff to accurately care for the residents. Review of the facility policy and procedure for Conducting an Accurate Resident Assessment, dated 2025, indicated the following [in part]: Policy:The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas.Definition: Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status) .

Based on observation interviews and record review the facility failed to ensure that residents were free of a med error of 5% or greater (7.69%) 2 of 6 residents who reviewed for medication errors . 1. The facility failed to ensure LVN A primed (removing air bubble to ensure that the needle is open and working) insulin pen for Resident #35 before administering Fiasp (insulin aspart) 2. The facility failed to ensure LVN B primed the insulin pen for Resident #37 before administering Fiasp (insulin aspart). 3. The facility had a 7.69% medication error rate based on 2 errors out of 26 opportunities, which involved 2 of 6 reviewed for pharmacy services. This failure placed resident at risk of increased doses of medications. The findings included: During an observation on 09/10/2024 at 11:23 AM LVN B administered Fiasp flex touch pen (insulin) 22 units to Resident #35 without priming the flex touch pen prior to administration. Review of Resident # 35's electronic face sheet revealed [AGE] year-old female admitted [DATE]. Diagnoses include Chronic Obstructive Pulmonary Disease (lung disease), Type 2 Diabetes Mellitus, Unspecified Protein-Calorie Nutrition. During an observation on 09/10/2024 at 07:05 AM LVN A administered Fiasp flex touch pen (insulin) 2 units to Resident # 37 without priming the flex touch pen prior to administration. Review of Resident #35's Physician Orders dated 09/01/2024 revealed, Fiasp flex touch subcutaneous solution Pen injector 100 unit/ML (Insulin Aspart) Inject as per sliding scale. Review of Resident #35's September 2024 MAR (medication administration record) revealed: Fiasp Flex touch pen was administered per sliding scale 9 of 10 days. Review of Resident #35's quarterly MDS ([NAME] Data Set) dated 06/04/2024 section C Cognitive Patterns BIMS (Brief interview mental status) revealed resident score 15 (cognitively intact). Review of Resident 35's Care Plan dated 06/04/2024 revealed, Problem: The resident has Diabetes Mellitus. Goal-the resident will have no complications related to diabetes through the review date. Review of Resident #37's electronic face sheet revealed, [AGE] year-old female admitted [DATE]. Diagnoses include Type 2 Diabetes Mellitus, Hypertension (high blood pressure), anxiety disorder. Review of Resident #37's Physician Orders dated 09/01/2024 revealed, Fiasp Flex touch pen 100 unit/ML (insulin aspart) inject per sliding scale. Review of Resident #37's annual MDS dated [DATE] revealed section C Cognitive Patterns BIMS score 15 (cognitively intact). Review of Resident #37's Care Plan dated 07/25/2024 revealed, Focus-The resident has Diabetes Mellitus. Goal- The resident will have no complications related to diabetes through the review date. Interventions- Diabetes medication as ordered by doctor. Monitor/document the side effects and effectiveness. Review of Resident #37's September 2024 MAR revealed Fiasp flex touch pen was administered per insulin sliding scale 11 days of 11 days. Fiasp Flex touch pen was administered 9 of 11 days 3 times per day and 2 of 11 days 2 times per day. During an interview on 09/10/2024 at 01:55 PM LVN A stated she did not prime the Fiasp flex touch pen before administration because she was not aware that the pen needed to be primed. LVN A stated this could lead to resident not getting all the insulin ordered. LVN A stated this could lead to resident's blood sugars to not be controlled. During an interview on 09/12/2024 at 11:24 AM the DON stated she was not aware of the need to waste/prime insulin pens before administration. The DON stated she did not feel that any residents were harmed by failing to prime insulin pens before administration. The DON stated this failure occurred due to not knowing insulin pens needed to be primed before administration. Review of facility's policy titled Insulin Injection Dated 01/13 Purpose to safely administer Subcutaneous Injection Expel air from the syringe Review of facility's policy titled Medication Administration dated 01/13 Purpose: To administer the following according to the principles of medication administration, including the right medication, to the right resident at the right time and in the right dose and routes.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with current accepted professional principles for 2 (West Hall Medication Cart and Treatment Cart) of 3 carts observed for medication storage. The facility did not ensure [NAME] Hall Medication Cart and Treatment Cart were locked and secure. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 9/10/24 at 7:16 AM revealed treatment cart parked in [NAME] hallway corner near bathroom with a resident within 6 feet away of open, unsecured cart. No nurse in sight of cart. Present in cart were medicated dressings, prescription ointments and creams, over the counter creams. In an interview on 09/10/2024 at 7:18 AM L VN B stated that both LVNs had keys to treatment cart and it was both responsibility to ensure cart was secure. LVN B further stated the cart should be locked if not in use or sight of nurse and failure to secure cart could lead to residents accessing medications and treatment dressings in cart. Observation on 9/11/2024 at 6:30 PM revealed medication cart unlocked and unattended on [NAME] hall. Cart was parked in middle of hall and nurse was in resident room. Nurse was not in line of sight of medication cart. Present in medication cart included over the counter medications, prescription medications; narcotic drawer was locked by one lock. Interview on 9/11/2024 at 6:31 PM LVN C stated the medication cart was to be locked at all times to prevent resident accessing medications that could harm them. LVN C further stated that it was her responsibility to ensure the medication cart was locked. Interview with the DON on 9/12/24 at 10:22 AM revealed her expectation is for medication and treatment carts to always be locked if not in use by nurse. The DON also stated if cart is not locked residents could get into cart and have a possibility of drug diversion. The DON further stated that nurse who receives the cart is responsible for making sure it is secure. In an interview on 9/12/24 at 10:40 AM the ADM stated that medication carts should be locked if not in use. The ADM continued stating that lack of securing medication carts could potentially allow the wrong person to get in cart and get medications that did not belong to them. Record review of policy Medication Administration from Nursing Procedure Manual dated 01/13 revealed the following [in-part]: 14. Lock medication cart before entering resident/patient room. Never leave the medication cart open and unattended.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: A. floors were swept and free from dirt and food crumbs. B. bottom shelves were clean. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status. The findings included: On 09/10/24 beginning at 6:40 AM, during the initial tour of kitchen, revealed refrigerator #1 had spilled, dry milk on the bottom in multiple areas, and underneath the shelves. In the corners and against the wall, there were dust and food crumbs. In the kitchen area, the floor was dirty with dirt and food crumbs and trash underneath the shelves and along the walls. In a follow-up interview and observation of the kitchen on 09/10/24 at 9:00 AM, there was no change in the soiled floors. In refrigerator #1, there was dry spilled milk in multiple areas and food crumbs underneath the shelves and along the bottom. The cleaning schedule posted and initialed by the assigned staff as task completed. In an interview with the Dietary Manager on 09/11/24 at 2:15 PM, The dietary manager stated the refrigerators were usually cleaned every Saturday by the evening cook but, she must not have done it last Saturday. She said there was a cleaning schedule that should be followed and initialed when the task was completed. She said that she was the person responsible for insuring the daily cleaning gets done but she is new to the job. She said she monitors the cleaning by checking the cleaning schedule for the employee's initials. On 09/10/24 at 2:30 PM review of the dietary cleaning schedule revealed several missing initials that signified that the cleaning tasks had been completed. In an interview with the Administrator on 09/12/24 at 3:00 PM, he said it was his expectation for the kitchen to be cleaned daily. If food was spilled, it should be cleaned up at that time. Failure to do so had the potential for infection and pests. A record review of the facility policy Cleaning and Disinfection of Environmental Surfaces, dated as revised August 2019, revealed the following [in part]: 9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. A record review of the facility policy Professional Appearance in the Workplace, dated May 2022, revealed the following [in part]: Review of the Food and Drug Administration Food Code, dated 2017, specified [in part]: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 (Resident #4) resident reviewed for infection control practices, in that: LVN C failed to perform hand hygiene and change gloves as appropriate while providing incontinence care for Resident #4. This failure could place resident's risk for cross contamination and the spread of infection. Findings included: Review of Resident #4's face sheet, dated 09/12/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unspecified dementia (memory loss), urinary tract infection, obesity (overweight) and depression (feeling of sadness). Review of Resident #4's Minimum Data Set (MDS) assessment dated on 07/26/24, revealed Resident #4 required dependence (helper does all effort) with most activities of daily living (ADLs) with two-person assistance. She was frequently incontinent of bowel and bladder. Active diagnosis revealed urinary tract infection. Review of Resident #4's physician order dated 8/8/24 revealed Resident #4 started new antibiotic medication Cefuroxime Axetil Oral Tablet 250 mg by mouth two times a day for ten days for urinary tract infection. Observation on 09/12/24 at 10:47 AM of incontinence care for Resident #4 revealed CNA D and CNA E transferred Resident #4 to bed side commode, LVN B removed the resident's brief. Resident #4 urinated and had bowel movement. CNA D and CNA E then assisted Resident #4 back to standing position. LVN B wiped the resident from front to back. LVN C gloves were soiled with urine and fecal matter but she continued to use. LVN C did not wash her hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident #4's clean brief. LVN C placed the clean brief on the resident and fastened it. In an interview on 09/12/24 at 11:03 AM LVN C stated that after performing pericare her gloves were dirty. LVN C stated mixing clean with dirty was cross contamination and she should have performed hand hygiene with glove change in between. LVN C further stated that cross contamination can lead to infections. LVN C stated that she had received infection control training. During an interview with the DON 09/12/24 at 11:12 AM she stated the staff were expected to use proper infection control techniques, proper hand hygiene and change gloves at appropriate times. The DON further stated that lack of proper infection control techniques could cause infections such as urinary tract infections. The DON stated she was responsible for infection control in the facility. Review of the Perineal Care in Nursing Procedure Manual revised April 2013 revealed the following [in part]: Policy: To promote cleanliness and prevent infection. Procedure: 13. Remove gloves, wash hands and apply clean gloves. 14. Apply ordered creams or ointments and/or skin barrier cream to prevent breakdown as needed. Remove gloves, perform hand hygiene, and apply clean gloves. 15. Assist resident with incontinent brief, underwear, appropriate garments.

Based on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 2 residents reviewed for quality of care (Resident #1). The facility failed to ensure the nurses initialed and dated wound dressings when wound care was performed on Resident #1. This failure could result in residents with wounds of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings include: Record review of face sheet dated 5/29/24 indicated Resident #1 was a [AGE] year-old female admitted initially to the facility on [DATE] and readmitted on [DATE] with diagnoses including TYPE 1 Diabetes (an autoimmune disease that originates when cells that make insulin are destroyed by the immune system), TYPE 2 Diabetes (high blood sugar, insulin resistance, and lack relative lack of insulin), Anemia (blood disorder in which the blood has reduced ability to carry oxygen), protein-calorie malnutrition (lack of energy due to the deficiency of all the macronutrients and many micronutrients), Hyperlipidemia (high levels of any or all lipids in the blood), Hypokalemia (low level of potassium in the blood serum), Cerebrovascular disease (arteries supplying oxygen to the brain are damaged). Record review of the physician orders dated 5/29/24 indicated Resident #1 had an order to cleanse right great toe with normal saline, pat dry, apply layer of hydrogel to wound bed followed by collagen sheet cut to fit wound bed. Cover with calcium alginate cut to fit wound bed, cover with non-adherent dressing, and secure with tape. Frequency: every day. Record review of the MDS dated [DATE] indicated Resident #1 had a BIMS of 8 and was moderately cognitive impaired. Record review of the care plan revised 5/13/24 indicated Resident #1 had a diabetic foot ulcer of the left great toe related to poor circulation with interventions including wound care as ordered. Record review of the TAR dated 5/24/24 through 5/28/24 indicated Resident #1 wound care treatment to the right great toe was being performed daily by facility. Interview on 5/29/24 at 1:35 am Resident #1 stated she received wound care daily and did not have any pain while care was being performed. During an observation and interview on 5/29/24 at 1:40pm, LVN A performed wound care on Resident #1. The wound dressing on the right great toe was not dated or initialed. LVN A stated she performed wound care yesterday and forgot to date and initial. LVN A removed the dressing and performed wound care following physician orders. LVN A stated the importance of performing wound care daily as ordered was because Resident #1's wound had been infected and would easily become infected again especially with her diagnoses of diabetes. LVN A stated it is important to date and initial wound care bandage because, if different nurses were working the hall, or the nurse was not going to be there the next day the dressing should be initialed and dated to show wound care has been performed. During an interview on 5/30/24 at 3:40 p.m. the DON stated she expected staff to date and initial wound dressings. The DON stated dating and initialing wound dressing verified the wound care was performed. The DON stated she expected staff to sign off on the TAR when wound care was completed. The DON stated if the TAR was not signed off and bandage was not dated and initialed there was no way to prove wound care had been performed as ordered. Record review of the facility's undated Dressing Change Procedure indicated Document date, time dressing changed, and initials on a piece of tape and place on dressing.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen in that: 1. The range was soiled with a built up, sticky grease like substance. 2. There were soiled wet towels and food crumbs on the floor. 3. There were dead crickets in standing water in the drain underneath the dishwasher an in the clean handwashing sink. 4. The commercial refrigerator contained one half of a watermelon covered in saran wrap and not dated, an opened block of butter was open to the refrigerator air and not dated or covered by an airtight container, an open plastic container of brown gravy dated 7/20, 1/2 water melon not dated and covered with saran wrap and an undated zip lock baggie of cut onions. 5. The Dietary Manager touched meat with her bare hand and placed it on the steam table with the meat served to residents 6. Metal piping directly above range and over vent hood covered in grease and brown dust lint like material, and a heavy black residue was noted along the corners and crevices of the dishwashing machine. 7. Employees hair and beard restraints did not cover their facial or head hair. The facility's failure placed residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated Findings included: Observations during the initial tour of the facility kitchen on 08/01/23, starting at 9:10 AM, revealed the following: - the floors in the kitchen dishwashing food preparation area had towels on the floor and standing water underneath the dishwashing sink drain. - They were dead crickets floating in the standing water. - Food crumbs were observed throughout the kitchen area on the floors and counter. - a heavy black appearing residue was noted along the corners of the dishwashing machine. - Food crumbs were observed under the sink, oven, and preparation areas. - Observation on 08/01/2023 at 9:30 AM revealed the following: - refrigerator unit contained 1 plastic container of opened brown gravy dated 07/20/23, - one open block of butter in an unsealed wrapping and not dated, or covered by an airtight container, - 1/2 of a watermelon covered with saran wrap and not dated. - cut onions in a zip lock bag with no date. In an interview 08/01/2023 at 9:40 AM the Dietary Manager stated the crickets were a problem all over town. The bug man said there is nothing that can be done about them. She stated the food items should be dated. She stated she does not have a cleaning list. She stated she used to make a cleaning schedule, but it did not do any good because her employees will not do the cleaning. She stated she was responsible for monitoring the kitchens cleanliness and ensuring foods were dated when opened. She stated her employees need to be written up, but the old administrator would not do anything about it. She stated an unclean kitchen and undated food could cause foodborne illness. Observation on 08/02/2023 at 10:00 AM revealed the floors appeared to be in the same condition and appeared to be remain unclean with food remaining from the previous day. Observation and interview on 8/02/2023 at 11:45 AM, during the lunch meal preparation, the Dietary Manager dropped a cooked chicken fried chicken patty on the counter and picked it up with her bare hand and placed it in the food holding tray with the remainder of the cooked chicken fried chicken., After the surveyor asked the Dietary Manger if she picked up the chicken from the warming tray with her bare hand, she stated Yes, I guess I did and picked it up with clean tongs and placed it on a plate on the counter by the stove . She stated she should not have picked the chicken up and placed it on the steam table with the rest of the prepared chicken because it could spread germs Observation 0n on 8/03/2023 at 11:50 AM revealed the burner knobs on the gas stove had a sticky, greasy residue. The [NAME] that ran along the wall directly over the oven on the wall had a greasy, thick dusty, residue behind the stove. There was a large commercial fan on the floor blowing toward the gas stove and steamer table during meal service. During an interview and observation on 8/3/23 @ 3:00 PM with the facility administrator present revealed 2 bearded male dietary employees were observed to have on baseball caps and no hair restraint. There, The beard restraints did not cover their facial hair. The Administrator stated it was her expectation that the beard restraints and hair restraints should be in place and cover the hair on the scalp and face. The administrator went into the kitchen and instructed kitchen employees in the necessity of wearing hair nets and beard restraints to avoid contamination of food and spread of foodborne pathogens. Review of the facility's Dietary Policy and Procedure Manual, revealed the following [in part]: The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Review of the Job description of the Dietary Manager dated effective 11/2022 revealed in part: Job summary - Manage the operations of the dietary department to include staffing, food ordering and preparation, food delivering and clean up, in accordance with facility policies, physician orders, care plans, and appropriate regulations. Sanitation - Ensure that dietary work areas are maintained in a clean and sanitary manner. Ensure food storage rooms, preparation areas, etc. are maintained in a clean safe and sanitary manner. Review of the U.S. Food and Drug Administration, 2022 Food Code, reflected: Review of The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Cleanability 4-202.11 Food-Contact Surfaces. (A) Multiuse FOOD-CONTACT SURFACES shall be: (1) SMOOTH; Pf (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; Pf (3) Free of sharp internal angles, corners, and crevices; Pf (4) Finished to have SMOOTH welds and joints Food storage/labelling 3-501.17 Ready-to-Eat food prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 3-701.11 Food that has been contaminated by an employee with their hands, or bodily discharges shall be discarded. 3.305.11 Food shall be protected from contamination by storing the food in a clean dry location, where it is no exposed to dust or other contaminants Chapter 6 Maintenance and Operations - Controlling Pests The premises shall be maintained free of insects, rodents, and other pests The presence of insects, rodents, and other pests, shall be controlled to eliminate their presence on the premises. Dead or trapped birds, insects' rodents, and other pests shall be removed from control devices and the premises at a frequency does not prevent their accumulation, decomposition, or the attraction of other pests.

45437 Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 3 of 7 residents (Residents #11, #26 and #27) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #11 and Resident #27 had a significant weight loss. The facility failed to complete a comprehensive MDS assessment after Resident #26 returned from the hospital and had a significant decline. These failures placed residents at risk of having assessment that do not reflect significant changes in their conditions and need for additional care/treatment. The findings included: Resident #11 Review of Resident #11's face sheet revealed Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), bipolar disorder (a mental disorder characterized by mood swings resulting depressive lows and manic highs), and anxiety. Record review of Resident #11's MDS schedule reflected an Annual MDS dated [DATE]; there was not a significant change assessment documented. Record review of the facility monthly weight report revealed Resident #11 weighed 139.8 in March 2023, 125.2 in April 2023, and 131.1 in May 2023 , which indicated the resident had lost 14.6 pounds in 30 days . Record review of Resident 11's MDS dated [DATE] Section K revealed the resident had not had a significant weight gain or loss in 30 or 180 days. Record review of Resident #11's care plan revealed that Resident #11 had a nutritional problem or potential nutritional problem R/T dysphagia (difficulty swallowing). Date Initiated: 05/01/2023. Goal: The resident will comply with recommended diet for weight reduction daily through review date. Interventions included: The resident will comply with recommended diet for weight reduction daily through review date. Provide and serve diet as ordered. Resident #26 Review of Resident ##26's Face Sheet generated 08/04/2023, reflected Resident #8 was an [AGE] year-old male who was initially admitted to the facility on [DATE], with a readmitted [DATE]. The resident had the following diagnoses: fracture of the left femur (broken femur), thrombocytopenia (low levels of platelets in the blood), tachycardia (fast heart rate), Orthopedic after care (care of orthopedic surgery). Review of Resident #26's MDS Schedule reflected the last assessment as a 5-Day assessment completed on 06/04/2023, there was not a significant change assessment documented. Review of Resident #26's MDS revealed in the following: Sections I (Diagnosis)- Fractures and other Multiple Trauma and Hip Fracture. Section J- Did the resident have a fall any time in the last month prior to admission/entry or reentry? Yes Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? Yes Did the resident have major surgery during the 100 days prior to admission? Yes Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay? Yes Other Orthopedic Surgery- Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot). Interview with the MDS-LVN on 08/03/2023 at 11:52 AM concerning Resident #26 revealed that the resident was sent to the hospital on 05/25/2023 for a fall with major injury. She revealed that he came back into the building, and she did not complete a Significant Change MDS. She revealed that he did have a decline and that she should have completed a Significant Change. She revealed that he returned back into the facility on [DATE] after orthopedic surgery, which required orthopedic aftercare. She said that she would be completing a modification on the MDS to correct her mistake. She revealed that this error could result in the resident's decline not being captured or care planned correctly. This failure would then result in a comprehensive care plan not being completed, which could cause the resident to not receive the care that would trigger from a Significant Change assessment. Resident #27 Review of Resident #27's face sheet, dated 08/04/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet diagnoses list included: arthritis right knee (primary); Parkinson's disease; major depressive disorder (a mood disorder that causes a feeling of constant sadness), recurrent with psychotic (a mental disorder that causes a disconnection from reality) symptoms; and hypertension. (High blood pressure) Review of Resident #27's MDS Schedule reflected the last assessment as a Quarterly assessment dated [DATE] on 06/04/2023/2023; there was not a significant change assessment documented. Record review of Resident #27's Quarterly MDS dated [DATE] Section K revealed the resident did not have a significant weight loss or gain in 30 days or 180 days. Record review of the facility monthly weight report revealed Resident #27 weighed 128.9 in May 2023, 117.1 in June 2023, and 112.5 in July of 2023 which would be a 16-pound total loss in a 3-month period indicating the need for a significant change in condition assessment to be completed. In an interview on 08/03/2023 at 2:30 PM the MDS-LVN stated she was the nurse responsible for doing MDS assessments and she was responsible for the accuracy of those assessments. She stated the facility followed the RAI manual for their policy on completion of the MDS. She stated she used information that was in the resident electronic chart to obtain her information. She stated an inaccuracy on the residents MDS could lead to the resident not receiving necessary care and services and result in a decline in the resident's health. She agreed that significant weight loss or gain would indicate a significant change in the resident's condition. Interview with the DON on 08/03/2023 at 3:00 PM revealed that it was the ADON (who was the past MDS coordinator) responsibility to make sure the assessments are completed accurately. She stated that this failure could cause her to miss care areas that would trigger on a significant change assessment. The facility's policy and procedure for Resident Assessments and/or Significant Changes was not provided at the time of exit.

41944 45437 Based on interview, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 6 of 17 residents (Residents #'s 11, 16, 27, 29, 35, and 36) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure Resident #11's most recent Annual MDS Assessment reflected a significant weight loss. The facility failed to ensure Resident #16's reflected the usage of a wheelchair harness under restraints. The facility failed to ensure Resident #27's Quarterly MDS accurately reflected her significant weight loss. The facility failed to ensure Resident #29's MDS documented the last attempt for a GDR. The facility failed to ensure Resident #35's MDS accurately reflected her weight loss. The facility failed to ensure Resident #36's Admission MDS accurately reflected his mood status. These failures by the facility placed residents at risk of not receiving the care and services to meet their needs. Findings included: Resident #11 Review of Resident #11's face sheet revealed Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnoses of heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), bipolar disorder (a mental disorder characterized by mood swings resulting depressive lows and manic highs), and anxiety. Record review of Resident #11's Annual MDS dated [DATE] Section K revealed the resident did not have a significant weight loss or gain. Record review of the facility monthly weight report revealed Resident #11 weighed 139.8 in March 2023, 125.2 in April 2023, and 131.1 in May 2023 . Record review of Resident #11's care plan revealed that Resident #11 had a nutritional problem or potential nutritional problem R/T dysphagia (difficulty swallowing). Date Initiated: 05/01/2023. Goal: The resident will comply with recommended diet for weight reduction daily through review date. Interventions included: The resident will comply with recommended diet for weight reduction daily through review date. Provide and serve diet as ordered. Resident #16 Review of Resident #16's face sheet revealed Resident #16 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (damage to the developing brain before birth), epilepsy (seizure disorder) and developmental disorder (serious impairment in different areas originating from childhood). Record review of Resident #16's Quarterly MDS dated [DATE] Section P revealed the resident did not have a trunk restraint. Section P on the MDS describes physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Record review of Resident #16's current care plan revealed the following areas: Focus: Resident is at risk of falling due to disease process related to Cerebral Palsy. Goal: Restraints used to prevent the resident from falls, will be minimized/eliminated by the review date. Focus: The resident uses physical restraints of an abdominal chair vest while in his wheelchair and seatbelt related to confusion and disease process. Resident cannot sit up om his own. Goal: The resident will remain free of complications related to restraint use, including contractures, skin breakdown, altered mental status, isolation, or withdrawal through review date Goal: Resident has Local Authority services due to being PASRR positive. Interventions: Resident received a custom manual wheelchair and abdominal chair vest and seatbelt due to the disease process and not being able to sit up on his own. Review of Resident's #16's Device Evaluation dated 03/31/2023 revealed the following: Condition/Circumstances for device- Reduces fall risk Identify type of device to be implemented: Restraints on wheelchair Review of Resident's #16's Device information and consent revealed the following: Physical restraints are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Restraint use signed off on 04/01/2022. Resident #27 Review of Resident #27's face sheet, dated 08/04/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet diagnoses list included: arthritis right knee (primary); Parkinson's disease ; major depressive disorder, recurrent with psychotic symptoms; and hypertension. Record review of Resident #27's Quarterly MDS dated [DATE] Section K revealed the resident did not have a significant weight loss or gain Record review of the facility monthly weight report revealed Resident #27 weighed 128.9 in May 2023, 117.1 in June 2023, and 112.5 in July of 2023 which would be a 16-pound total loss in a 3-month period. Record review of Resident #27's care plan revealed the care plan was last revised on 5/16/23 and there was no weight loss or potential for weight loss care planned. Record review of Resident #29's Admission record revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: schizoaffective disorder (a combination of schizophrenia (disorder that affects a person's ability to think, feel and behave correctly) and mood disorder); unspecified psychosis (severe mental condition in which thought and emotion are so affected that contact is lost with external reality). Record review of Resident #29's Monthly Medication Regimen Review Note to Attending Physician, dated 3/27/23 revealed a GDR was recommended and the physician declined to make an attempt. Resident #29 Record review of Resident #29's Quarterly MDS dated [DATE], revealed Section N0450, C. Date of last attempted GDR: did not have a date of the last attempted GDR documented and Section N0450, E. Date physician documented GDR as clinically contraindicated: as 06-03-2022 . In an interview on 08/04/23 02:30 PM with the MDS Coordinator concerning Resident #29's latest MDS not having the correct date for the last GDR attempt that was done. The MDS Coordinator said that she did not know that one was done because that information was not shared with her. She stated due to her not knowing she was not able to put the most recent date into the MDS . Resident #35 Review of Resident #35's face sheet, dated 08/04/23, revealed an [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis included: senile degeneration of the brain (primary); moderate dementia with behavioral disturbance; repeated falls; fracture of left femur; protein calorie malnutrition, anemia; dysphagia (difficulty swallowing); dehydration; and arteriosclerotic heart disease (hardening of the arteries). Record review of Resident #35's Significant Change MDS dated [DATE] Section K revealed the resident weighed 116 pounds and did not have a significant weight loss. Record review of the facility monthly weight report revealed Resident #35 weighed 108.2 in May 2023, 115.7 in June 2023, and 98.3 in July 2023. Resident #36 Record review of Resident #36's Face Sheet, dated 08/04/23, revealed resident was an [AGE] year-old male, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. diagnoses included: hypertensive heart disease (primary) metabolic encephalopathy; vascular dementia, unspecified severity with anxiety; delusional disorder; unspecified convulsions, fecal incontinence; and urinary incontinence. Review of Resident #36's Admission MDS dated [DATE], section D0200 Mood revealed Resident #36 had no thoughts of harming himself or feelings of hopelessness. He had a BIMS score of 10 (moderate cognitive impairment) and had no behaviors. Resident #36 review of psychoactive drug consent form dated, 7/11/23 revealed he had Haldol (an antipsychotic drug) ordered IM on 7/12/23 for behaviors of aggression, delusions, and hallucinations. Review of Resident #36's care plan revealed resident took Seroquel (an antipsychotic) for a delusional disorder /record occurrence of for target behavior symptoms such as spacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document . In an interview on 08/02/2023 at 12:05 PM with the MDS-LVN concerning Resident #16, she revealed that she believed she should have coded him as having a restraint on Section P, but she was told by a prior regional consultant (who is no longer employed), that she should not code it as being a restraint. She revealed that she completed an observation of the resident and that he was unable to release the restraint on his own. She revealed that he was not able to take the restraint off. She stated that she uses the RAI manual as a guideline for what to code and not code. She stated this failure could place the resident at risk of receiving an inaccurate assessment which could lead to the resident not receiving necessary care and services and result in a decline in the resident's health. In an interview on 08/02/2023 at 3:30 PM with the DON concerning Resident #16, she revealed that the resident was not able to release the wheelchair harness on his own. She said that they completed observations, obtained consent and orders, and care planned the wheelchair harness. She stated that the trunk restraint was used to prevent the resident from falling as stated in the care plan. She was unsure why it was coded on the MDS as not being a restraint. In an interview on 08/03/2023 at 2:30 PM the MDS-LVN stated she was the nurse responsible for doing MDS assessments and she was responsible for the accuracy of those assessments. She stated the facility followed the RAI manual for their policy on completion of the MDS. She stated she used information that was in the resident electronic chart to obtain her information. She stated an inaccuracy on the residents MDS could lead to the resident not receiving necessary care and services and result in a decline in the resident's health. In an interview on 08/04/2023 at 02:30 PM with the MDS Coordinator concerning Resident #29's latest MDS not having the correct date for the last GDR attempt that was done. The MDS Coordinator said that she did not know that one was done because that information was not shared with her. Due to her not knowing she was not able to put the most recent date into the MDS . Review of CMS'S RAI Version 3.0 Manual version 1.17.1 dated October 2019 revealed: The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status (2) a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (3) the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts.

45437 Based on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 6 of 15 residents (Resident #s 7, 16, 26, 27, 35 and 36) whose records were reviewed for baseline careplans, in that: 1. Resident #7 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 2. Resident #16 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 3. Resident #26 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 4. Resident #27 did not have a base line care plan developed and implemented following admission to the facility on [DATE]. 5. Resident #35 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. 6. Resident #36 did not have a base line care plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. The findings included: Resident #7 Record review of Resident #7's Face Sheet, dated 08/04/23, revealed resident was an a [AGE] year-old male, who was initially admitted to the facility on [DATE]. Diagnosis diagnoses included: dementia (thought process that interferes with daily function), delusional disorder (altered reality), psychotic mood disorder (mental condition that causes you to lose touch with reality, main symptoms are delusions and hallucinations), delirium (confused thinking and reduced awareness of surroundings), psychotic disturbance (psychosis, altered thinking) and mood disturbance (altered mood). Review of Resident #7's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE]. The comprehensive care plan was dated as initiated 08/02/23. Resident #16 Record review of Resident #16's Face Sheet, dated 08/04/23, revealed resident was an a [AGE] year-old male, who was initially admitted to the facility on [DATE]. Diagnosis diagnoses included: Cerebral Palsy (damage to the developing brain before birth), epilepsy (seizure disorder) and developmental disorder (serious impairment in different areas originating from childhood). Review of Resident #16's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE]. The comprehensive care plan was dated as initiated 04/04/22. Resident #26 Review of Resident #26's face sheet, dated 05/29/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet diagnoses list included: Fracture of left femur (break in femur), hypertension (high blood pressure), tachycardia (high heart rate) and thrombocytopenia (low blood platelet). Review of Resident #26's clinical record revealed a base line care plan had not been completed following her admission into the facility on [DATE]. The comprehensive care plan was dated as initiated 07/13/23. Resident #27 Review of Resident #27's face sheet, dated 08/04/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet diagnoses list included: arthritis right knee (primary); Parkinson's disease; major depressive disorder, recurrent with psychotic symptoms; and hypertension. Review of Resident #28's clinical record revealed a base line care plan had not been completed following her admission into the facility on [DATE]. The comprehensive care plan was dated as initiated 02/15/23. Resident #35 Review of Resident #36's face sheet, dated 08/04/23, revealed an [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis diagnoses included: senile degeneration of the brain (primary); moderate dementia with behavioral disturbance; repeated falls; fracture of left femur; protein calorie malnutrition, anemia; dysphagia (difficulty swallowing); dehydration; and arteriosclerotic heart disease (hardening of the arteries). Review of Resident #36's clinical record revealed a base line care plan had not been completed following her initial admission into the facility on [DATE]. The comprehensive care plan was dated as initiated 08/03/23. Resident #36 Record review of Resident #36's Face Sheet, dated 08/04/23, revealed resident was an [AGE] year-old male, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis diagnoses included: hypertensive heart disease (primary) metabolic encephalopathy (decline in brain function due to liver disease); vascular dementia (brain damage due to multiple strokes) , unspecified severity with anxiety; delusional disorder (disorder where reality is not accurate); unspecified convulsions (seizures), fecal incontinence; and urinary incontinence. Review of Resident #36's clinical record revealed a baseline care plan had not been completed following the resident's initial admission to the facility on [DATE] or after her readmission on 07/11/23. The comprehensive care plan was dated as initiated 08/03/23. In an Iinterview with the MDS coordinator and DON on 08/03/23 they stated the form titled Baseline care plan in the Resident's EMR's were not a care plan. They both revealed that staff such as CNA's do not have access to the care plan assessments that are completed. They were only assessments that were meant to obtain information to complete the baseline care plan. They stated the failure places residents at risk for not getting needed care. The DON revealed that an LVN completes them, but she is responsible for reviewing them upon completion. She revealed that she had not been doing that for all of the residents. Review of the facility's policy and procedure titled Care Plan development dated - Preliminary, dated 8/15, revealed the following [in part]: Policy Statement An interim care plan will be developed within 24 hours of admission. To assure resident's immediate needs are met this care plan will be initiated by nursing or designed and developed further as needed until the comprehensive plan is complete. This may include but not limited to the following: o Risk for falls. o Pain o Activity of daily living needs or strengths. o Skin condition o Incontinence o Mood and/or Behaviors

45437 Based on interview and record review, the facility failed to complete a comprehensive care plan within 7 days after completion of the comprehensive assessment for 9 of 15 residents (Resident #7, Resident #11, Resident #16, Resident 18, Resident #22, Resident #26, Resident #27, Resident #35, and Resident #36) whose records were reviewed for assessments and care plans timing., as well as having an IDT team present at the care conference. The facility failed to ensure that Resident #7, Resident #11, Resident #16, Resident #18, Resident #19, Resident #22, Resident #26, Resident #35, and Resident #36 had care plan developed and updated within 7 days following the completion of the MDS as well as having an Intradisciplinary Team present at the care conference. This failure could place residents at risk of not have having their care plans completed accurately and timely and having the appropriate staff involved in the decision making for their care Findings included: Resident #7- Record review of Resident #7's face sheet revealed resident was a [AGE] year-old male who was admitted to the facility 05/22/2023. Resident #7 had diagnoses which included Delusional Disorder (mental illness in which a person has delusions), hypertension (high blood pressure), Atrial fibrillation (irregular often rapid heart rate), dementia (decline in cognitive abilities), repeated falls and psychotic disorder (mind cannot determine what is real or not real). Record review of Resident #7's Admission MDS assessment, dated 05/28/2023, revealed the following: Section C revealed the resident had a BIMS score of 14 (cognitively intact). Record review of Resident #7's electronic Care Conference record revealed he did not have a care plan until 08/02/2023. Resident #11 Review of Resident #11's face sheet revealed Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis diagnoses of heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (a group of lung diseases that block air flow and make it difficult to breath), bipolar disorder (a mental disorder characterized by mood swings resulting depressive lows and manic highs), and anxiety. Record review of Resident #11's Annual MDS assessment, dated 04/08/2023, revealed the following: Section C revealed the resident had a BIMS score of 5 (severe cognitive impairment). Record review of Resident #11's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 04/08/2023 MDS. Record review of Resident #11's Quarterly MDS assessment, dated 07/09/2023, revealed the following: Section C revealed the resident had a BIMS score of 7 (severe cognitive impairment). Record review of Resident #11's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 07/09/2023 MDS. Resident #16- Record review of Resident #16's face sheet revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis diagnoses of Cerebral Palsy (damage to the developing brain before birth), epilepsy (seizure disorder) and developmental disorder (serious impairment in different areas originating from childhood). Record review of Resident #16's Quarterly MDS assessment, dated 10/22/2023, revealed the following: Section C revealed the resident had a BIMS score of 99 (unable to answer questions). Record review of Resident #16's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 10/22/2023 MDS . Record review of Resident #16's Quarterly MDS assessment, dated 01/14/2023, revealed the following: Section C revealed the resident had a BIMS score of 99 (unable to answer questions). Record review of Resident #16's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 01/24/2023 MDS. Record review of Resident #16's Annual MDS assessment, dated 04/14/2023, revealed the following: Section C revealed the resident had a BIMS score of 99 (unable to answer questions). Record review of Resident #16's Comprehensive Care Conference notes, dated 04/21/2023, revealed he did not have a care plan completed and signed until 08/02/2023 Record review of Resident #16's Quarterly MDS assessment, dated 07/15/2023, revealed the following: Section C revealed the resident had a BIMS score of 99 (unable to answer questions). Record review of Resident #16's Care Conference notes, dated 07/20/2023, did not have a care plan completed and signed until 08/02/2023 Resident #18- Review of Resident #18's face sheet revealed Resident #18 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis diagnoses of diabetes, fracture of right femur, chronic respiratory failure , urinary tract infection, altered mental status and history of falls Record review of Resident #18's Annual MDS assessment, dated 05/17/2023, revealed the following: Section C revealed the resident had a BIMS score of 12 (moderate cognitive impairment). Record review of Resident #18's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 05/18/2023 MDS. The care plan was not revised and completed until 08/02/23 Record review of Resident #18's Quarterly MDS assessment, dated 05/13/2023, revealed the following: Section C revealed the resident had a BIMS score of 12 (moderate cognitive impairment5 Record review of Resident #18's Care Conference notes revealed did not have a care conference completed and signed 7 days after the 05/17/2023 MDS. Resident #22- Record review of Resident #22's face sheet revealed resident was a [AGE] year-old female who was admitted to the facility 01/30/2020 and a readmitted [DATE]. Resident #26 had diagnoses which included Parkinson's (disorder of the central nervous system that affects movement causing tremors), Bipolar (mental disorder that results in mood swings), Hypertension (high blood pressure), Major Depressive Disorder (depression that last more than 2 weeks). Record review of Resident #22's Quarterly MDS assessment, dated 09/21/2022, revealed the following: Section C revealed the resident had a BIMS score of 06 (severe cognitive impairment). Record review of Resident #22's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 09/21/2022 MDS. Record review of Resident #22's Quarterly MDS assessment, dated 12/16/2022, revealed the following: Section C revealed the resident had a BIMS score of 06 (severe cognitive impairment). Record review of Resident #22's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 12/26/2022 MDS. Record review of Resident #22's Annual Change MDS assessment, dated 01/19/2023, revealed the following: Section C revealed the resident had a BIMS score of 06 (severe cognitive impairment). Record review of Resident #22's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 01/19/2023 MDS Record review of Resident #22's Quarterly MDS assessment, dated 04/21/2023, revealed the following: Section C revealed the resident had a BIMS score of 06 (severe cognitive impairment). Record review of Resident #22's Care Conference notes, dated 04/21/2023, revealed he did not have a care plan completed and signed until 08/02/2023 Record review of Resident #22's Significant Change MDS assessment, dated 05/25/2023, revealed the following: Section C revealed the resident had a BIMS score of 06 (severe cognitive impairment). Record review of Resident #22's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 05/25/2023 MDS. Resident #26- Record review of Resident #26's face sheet revealed resident was a [AGE] year-old male who was admitted to the facility 02/28/2018 and a readmitted [DATE]. Resident #26 had diagnoses which included fracture of the left femur (broken femur), thrombocytopenia (low levels of platelets in the blood), tachycardia (fast heart rate), Orthopedic after care (care of orthopedic surgery). Record review of Resident #26's Quarterly MDS assessment, dated 10/14/2022, revealed the following: Section C revealed the resident had a BIMS score of 07 (severe impairment). Record review of Resident #26's Care Conference notes, dated 10/28/2022, revealed he did not have a care plan completed and signed until 11/10/2022. Record review of Resident #26's Annual MDS assessment, dated 01/12/2023, revealed the following: Section C revealed the resident had a BIMS score of 07 (severe impairment). Record review of Resident #22's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 01/12/2023 MDS. Record review of Resident #26's Quarterly MDS assessment, dated 03/01/2023, revealed the following: Section C revealed the resident had a BIMS score of 07 (severe impairment). Record review of Resident #22's Care Conference notes revealed he did not have a care conference completed and signed 7 days after the 03/01/2023 MDS. Record review of Resident #26's Quarterly (later modified to a Significant Change) MDS assessment, dated 06/04/2023, revealed the following: Section C revealed the resident had a BIMS score of 10 (moderate impairment). Record review of Resident #26's Care Conference notes, dated 07/13/2023, revealed he did not have a care plan completed and signed until 05/02/2023 Resident #27 Review of Resident #27's face sheet, dated 08/04/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The face sheet diagnoses list included: arthritis right knee (primary); Parkinson's disease (a neurological disorder affecting movement; major depressive disorder (severe recurring feelings of sadness and despair), recurrent with psychotic symptoms; (mental disorder that is exhibited by disconnection with reality) and hypertension (high blood pressure). Record review of Resident #27's Admission MDS assessment, dated 01/19/2023, revealed the following: Section C revealed the resident had a BIMS score of 99 (resident unable to answer questions). Record review of Resident #27's care conference notes revealed there was not a care plan completed until 08/02/2023. Resident #35- Review of Resident #35's face sheet, dated 08/04/23, revealed an [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis diagonses included: senile degeneration of the brain (decreased brain function), moderate dementia (memory loss) with behavioral disturbance; repeated falls; fracture of left femur ; protein calorie malnutrition (inadequate nutrition), anemia; dysphagia (difficulty swallowing); dehydration; and arteriosclerotic heart disease (hardening of the arteries). Record review of Resident #35's Significant Change MDS dated [DATE] Section C revealed the resident had a BIMS score of 3 (severe cognitive) impairment. Resident Record review of Resident #35's care conference notes revealed there was not a care plan completed until 08/03/2023. Resident #36 Record review of Resident #36's Face Sheet, dated 08/04/23, revealed resident was an [AGE] year-old male, who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis diagnoses included: hypertensive heart disease (changes in the chambers of the heart and coronary arteries as a result of chronic high blood pressure) metabolic encephalopathy (chemical imbalance of the blood that can result in delirium); vascular dementia (a common form of dementia caused by impaired blood supply to the brain), with anxiety; delusional disorder; unspecified convulsions (seizures) fecal incontinence; and urinary incontinence. Record review of Resident #36's Admission MDS assessment, dated 0723/2023, revealed the following: Section C revealed the resident had a BIMS score of 10 (resident unable to answer questions). Record review of Resident #36's care conference notes revealed there was not a care plan completed until 08/02/2023. In an interview on 08/04/2023 at 9:00 AM, the DON revealed that she was not responsible for the care plans, the MDS-LVN was after completion of the MDS assessment. She revealed that even though they were not completed timely and in full, she still ensured that she had been monitoring the residents and they had received the care. In an interview on 08/04/2023 at 10:30 AM, the MDS-LVN coordinator revealed that she was unsure how long she had to complete a care plan or a comprehensive care plan, she said she thought it was 30 days. When asked why the care plans were all completed late, she said that she just got behind and was not sure how to really do them. She said she had not been trained adequately on care plans and that the entire building was completed that way. When asked what way, she said that she would complete them when she could. She said that the IDT meeting was completed when they were able to do them. She said she stayed up the night before and went through and updated and completed the entire buildings care plan. She said every resident was not completed correctly and she could see where they were not signed, or it shows they were not completed. She revealed that none of them were done accurately and timely. She said this failure would place the residents at risk for inaccurate care plans and assessments which could cause a quality-of-care issue. She revealed that even though the care plans were not completed correctly. She stated that purpose of the care plan was to help staff members know how to care for the residents and meet their needs. Record review of the facility's policy titled: Care Plan Development dated 08/2015 revealed the following: Care Plan Development- An individualized, comprehensive care plan using the results of the RAI/MDS assessment, resident/family/legal representative and interdisciplinary input will be developed for each resident in the facility within 21 days of admission or 7 days after the completion date of a comprehensive MDS assessment and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan will include measurable objectives, interventions, goals, and timetables. The care plan will be reviewed and revised on an as needed basis and at least every 92 days. The comprehensive care plan is developed by the interdisciplinary team with input from the resident/family/legal guardian and information derived from the MDS/CAA assessment. The resident and or family/legal guardian have the right to decline participation in the development of the care plan or decline treatment. The declination will be documented in the medical chart. A summary of the resident's care plan and a copy of any advanced directives shall accompany each resident discharged , or transferred to another facility, or shall be forwarded to the receiving facility as soon as possible consistent with good medical practice. 3. Comprehensive care plans are designed to: o Include identified resident needs and strengths. o Include risk factors associated with needs o Build upon resident strengths and abilities. o Indicate goals and objectives that are measurable and obtainable and are derived from information supplied by resident/family/legal guardian and MDS data. o The care plan will be reviewed and revised as needed when a significant change in condition is noted, when outcomes were not achieved or when outcomes are completed, and at least every 92 days. o Distinguish team members responsible for each component of care o The interdisciplinary team includes but not limited to: a. Attending Physician. b. RN, LPN, CNA. c. Dietary Manager/Registered Dietician. d. Activity/Recreational Director. e. Therapist (OT, PT, ST) f. Social Worker g. Director of Nursing h. Consultants I. Others as necessary to meet the needs of the resident.

45437 Based on observations, interview and record review, the facility failed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #22) of two residents reviewed for infection control techniques in that: 1. CNA B did not wash her hands or conduct any hand hygiene practices after passing our trays, touching her hair and assisting other residents before feeding Resident #22. This deficient practice could affect residents and could result in cross contamination and infections. The findings were: Record review of Resident #22's face sheet revealed resident was a [AGE] year-old female who was admitted to the facility 01/30/2020 and a readmitted [DATE]. Resident #22 had diagnoses which included Parkinson's (disorder of the central nervous system that affects movement causing tremors), Bipolar (mental disorder that results in mood swings), Hypertension (high blood pressure), Major Depressive Disorder (depression that last more than 2 weeks). Record review of Resident #22's Significant Change MDS assessment, dated 05/25/2023, revealed the following: Section C revealed the resident had a BIMS score of 06 (severe cognitive impairment). Section K revealed a mechanically altered diet. Record review of Resident #22's Care Conference completed and dated 08/02/2023 revealed the following: Focus: The resident has a swallowing problem related to coughing or choking during meals or swallowing medications. Goal: The resident will have clear lungs, no signs and symptoms of aspiration through the review date. Observation and Interview on 08/01/2023 beginning at 12:23 PM revealed CNA A assisting Resident #22 in the dining hall. She passed trays, uncovered drinks, applied aprons and helped with assisting residents with feeding. After completing these tasks, she did not perform hand hygiene, but went directly to feeding Resident #22. She repeated this pattern multiple times, while touching her face, phone, and hair. When asked what the policy was on hand hygiene, she replied that should always perform hand hygiene in between feeding residents and after touching anything else. During an interview at this time, she revealed that she had been trained on proper hand washing but had just got distracted and this was a one-time mistake. She revealed that this failure could cause the resident's to be subjected to cross-contamination of germs, which could lead to an infection control issue. She immediately went and performed hand hygiene. Review of facility policy and procedure on Infection Control was not received at the time of exit

Based on observation, interview and record review, the facility failed to coordinate the assessment of one Resident, (Resident #7) of three residents with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations. The facility did not identify Resident #7 as having mental illness with a primary diagnosis of dementia that would require a PASRR 1012 form or a new PL1 form. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment. The findings were: Review of Resident #7's Face Sheet and Orders dated 08/04/2023 revealed he a was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7's diagnoses included: dementia (thought process that interferes with daily function), delusional disorder (altered reality), psychotic mood disorder (mental condition that causes you to lose touch with reality, main symptoms are delusions and hallucinations), delirium (confused thinking and reduced awareness of surroundings), psychotic disturbance (psychosis, altered thinking) and mood disturbance (altered mood). Review of Resident #7's's Physician Orders dated 08/04/2023 revealed a psych service consult on 07/15/2023 for an order of RisperDAL Oral Tablet 0.5 MG (Risperidone) Give 0.5mg by mouth in the morning related to delusion disorder; start date 07/15/2023 and RisperDAL Oral Tablet 0.5 MG (Risperidone) Give 1.5mg by mouth at bedtime related to delusional disorder; start date 07/15/2023. Review of Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 could usually understand others and was usually understood by others; had a severe cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 14. (Cognitively intact). No mood or behavior concerns were indicated. Review of Resident #7's Care Plan dated 08/02/2023 revealed the following: Focus: The resident uses psychotropic medications Risperdal for diagnosis of delusional disorder Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Review of Resident #7's PASRR Level One Screening Forms dated 05/23/2023, (after the resident's admission into the facility) was completed by the MDS Coordinator revealed Resident #7 had no diagnosis of mental illness, intellectual disability, or developmental disability. The MDS-LVN updated and resubmitted the form in the online portal to reflect that the was positive for mental illness on 08/01/2023. Review of Resident #7's records revealed there was not a 1012 form (dementia/Alzheimer's) completed . In an interview on 08/01/2023 at 10:30 AM with the MDS coordinator revealed that the resident should have had a yes for mental illness with his PL1 form. She stated that she did not complete one due to him having dementia as a primary diagnosis. When asked if she completed a 1012 PASRR form, she said that she had never even heard of that form. She stated that she had not been trained on the forms. She said by not accurately showing the residents mental illness through PASRR, it could cause the resident to not receive PASRR services . On 08/04/2023 a copy of the facilities policy and procedures titled: Preadmission screening for MI dated 02/2017 revealed the following: 1. Verify resident/patient has had a Level I MR/MI screen and it is filed in the medical record. Screen is completed on State specific/mandated form. 2. Verify that the appropriate State-designated agency is contacted for any resident/patient requiring a MI/MR Level II screen: o Admission o Significant Change o Upon diagnosis of an MI/MR previously unknown or undetermined

45437 Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 2 of 4 residents (Resident #11 and Resident #17) reviewed for respiratory orders in that: Resident #11 did not have her oxygen flow rate set at 2 liters per continuously as ordered by her physician. Resident #17 had her nebulizer mask that was not bagged and left lying on her nightstand uncovered. This these deficient practices could affect the residents who used oxygen and nebulizer treatments and could result in residents receiving incorrect or inadequate respiratory support and could result in a decline in health. The findings were: Resident #11 An observation and interview of Resident #11 on 08/01/2023 at 10 AM revealed Resident #11 sitting in her recliner with her light out and her feet and legs elevated in her chair had her O2 nasal cannula in her nostrils. and Tthe O2 tubing was dated, but the oxygen concentrator was not turned on. Respirations were even and unlabored. The resident denied shortness of breath. She stated she wore her oxygen continuously. She stated she did not realize her oxygen was not turned on. Review of Resident #11's face sheet revealed Resident #11 was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis diagnoses of heart failure, chronic respiratory failure, chronic obstructive pulmonary disease (, a group of lung diseases that block air flow and make it difficult to breath), bipolar disorder (a mental dis order characterized by mood swings resulting depressive lows and manic highs), and anxiety. Review of Resident #11's Annual MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 05 (severe cognitive impairment). Section O revealed: Oxygen in use while in the facility. Record review of Resident #11's care plan last revised on 02/09/2022 revealed the following: Focus- The resident has Oxygen therapy and is on 2 liters per minute via nasal canula routinely. Review of rResident #11's Consolidated Physician's Orders revealed dated 08/04/2023 revealed orders for oxygen 2 liters per minute via nasal cannula continuously. An interview and with the DON on 08/1/23 at 11:30 AM revealed that that the charge nurse was the one who was responsible for monitoring the resident's oxygen. In an interview and observation on 8/1/23 at 10:10 AM LVN #A stated the resident's oxygen should be on continuously and it must have been accidently turned off when she was assisted up in her chair. She checked the plug and set the oxygen at 2 liters per minute. She stated the failure to have the oxygen on for an extended period could result in respiratory distress. Resident #17 An observation and interview of Resident #17 on 08/01/2023 at 9:28 AM revealed that this resident was lying in bed watching TV with her nebulizer mask sitting beside her on the nightstand uncovered. She revealed that she had just had a breathing treatment that morning and that when the breathing treatment was completed, she would set the mask on the nightstand. She stated that it was usually uncovered because she just sets it there. She stated that the nurse that gave her the breathing treatment had already left for the day. Review of Resident #17's face sheet revealed Resident #17 was [AGE] year-old female who was initially admitted to the facility 01/17/2023 with a re-admitted [DATE] with a diagnoses diagnosis of heart failure (heart does not pump blood adequately), asthma (disease where the airway becomes inflamed), chronic obstruction pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe, dependence of supplemental oxygen (must have oxygen to survive breathe), and abnormal finding in the lung field (lungs are not properly functioning). Review of Resident #17's Quarterly MDS assessment dated [DATE] revealed the following: Section C revealed a BIMS score of 10 (moderately impaired). Section J revealed: Shortness of breath with exertion and while lying flat. Section O revealed: Oxygen in use while in the facility. Record review of Resident #17's care plan dated 08/03/2023 revealed the following: Problem- Asthma Approach- Give nebulizer treatments and oxygen therapy as ordered. Give medications as ordered. Monitor/document side effects and effectiveness. Review of resident #17 Physician's Orders revealed dated 08/24/2023 revealed the following orders for nebulizer treatments: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally every 6 hours as needed for shortness of breath. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally three times a day related to Asthma. An interview with the DON on 08/03/2023 at 3:30 revealed that she was the one who was responsible for all the nursing staff in the building. She was unsure who left the mask uncovered on the resident's nightstand, but that she was going to in-service and re-educate her staff. She revealed that failing to cover a mask could result in a respiratory infection. She said that all staff members know and have been trained that mask are to be covered at all times when not in use. A review of the facility policy titled Medication Administration on Nebulizers dated January 2013 revealed the following: After treatment is complete- Store the dry nebulizer in a storage bag labeled with resident/patient's name and date. 8. If the resident refused the procedure, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. A copy of the facility policy was requested to the DON covering Oxygen Administration and not provided at the time of exit .

Based on observation, interview, and record review facility failed to maintain an accurate record of the disposition of all controlled drugs and failed to destroy medications for destruction in that: DON failed to count and sign off on the medication sheets before they were put in storage for destruction. The facility failed to do a final count for the following controlled medications- Hydrocodone-Acetaminophen 10-325 (QTY 23), Clonazepam 0.5 MG (QTY 8), Hydrocodone-Acetaminophen 5-325MG (QTY 40) These failures could place the residents at risk of losing their medications in a drug diversion which could result in delayed healing. Findings Include: During an observation and interview on 08/03/2023 at 1:25 PM with the DON, revealed 3 controlled medication packs which contained Hydrocodone-Acetaminophen 10-325 (QTY 23), Clonazepam 0.5 MG (QTY 8), Hydrocodone-Acetaminophen 5-325MG (QTY 40) in the Controlled Substance cabinet in the DON's office was a cabinet that they put discontinue controlled medications that were set to be destroyed. The DON revealed that she was given the medication the day before but did not have time to do a count before it was given to her by the prior nurse. She stated that the medications were a controlled medication and that there should always be two signatures on the pack, one from the nurse passing the medication and another signature for the nurse that is receiving the medication. She stated that it is their policy to complete and do a final count (which to have 2 nurses count the medication) and that she always does, but she just got busy. She stated that this could place the residents at risk of losing their medications by a drug diversion. Record review of the facility's policy entitled; Storage of Controlled Substances revised August 2020 revealed the following: At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed personnel, and is documented.

Based on observations and interviews the facility failed to ensure drugs and biological used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory cautionary instructions, and the expiration date when applicable for 1 of 1 medication rooms. The Medication Room had expired and discontinued medication and biologicals. This failure could the residents who resided in the facility at risk of receiving expired medications Findings included: During an observation on 08/01/2023 at 10:41 AM, the medication room cabinet contained a box of Albuterol Sulfate Inhalation Aerosol prescribed to Resident #33 . The medications had been dispensed on 04/25/2022 with a discard by date of 04/25/2023. During an interview on 08/01/2023 at 11:00 AM with the DON, revealed that it was expired, and it should have been thrown out when they did their weekly audit of the medications . She revealed that she was responsible for ensuring it was completed. She revealed that they must have just missed it. She stated that this failure could place the residents at risk for receiving expired meds. She said she was responsible for ensuring that it was completed and that there were no expired medications. On 08/04/2023 the policy covering expired medications was requested to the Administrator but was not available at the time of exit.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to conduct the functions of the food and nutrition service for 1 of 1 (DM) reviewed for qualified dietary staff. The facility failed to ensure the facility's DM met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: Record review of the DM's employee file revealed a hire date o 02/10/2016 There was no documented evidence of a Dietary Manager Certificate found in the file. In an interview on 8/03/2023 at 10:30M the DM stated she did not have her dietary manager certification. She stated she did not think it was still a requirement for the dietary manager to be certified . She stated she did have a current food handlers' certificate. In an interview on 08/03/2023 at 2:00 PM the administrator stated she had been employed at the facility for 4 months, she stated it was her expectation that the Dietary Manager would have completed a food service manager's course and have a current certification as a Dietary manager. She stated the failure could result in the resident's not having their nutritional needs met and place them at risk for foodborne illness. Review of the Job description of the Dietary Manager dated effective 11/2022 revealed in part: Job summary - Manage the operations of the dietary department to include staffing, food ordering and preparation, food delivering and clean up, in accordance with facility policies, physician orders, care plans, and appropriate regulations. Sanitation - Ensure that dietary work areas are maintained in a clean and sanitary manner. Ensure food storage rooms, preparation areas, etc. are maintained in a clean safe and sanitary manner. Review of the U.S. Food and Drug Administration Food Code Chapter 2---102.11, dated 12/2022 stated the following in part: Based on the inherent risks related to food operation during inspection and on request the person in charge shall demonstrate to the regulatory authority knowledge of foodborne disease, prevention, application of the hazard analysis, and critical control point analysis. The person in charge will demonstrate this knowledge by complying with the food code and having no violations of priority items during the current inspection, being a certified food production manager who has shown proficiency of required information through passing a test that is part of an accredited program.

Based on observation, interview and record review the facility failed to ensure residents were able to exercise their rights and be free of interference, coercion and reprisal for 1 of 5 (# 1) residents reviewed for residents rights by failing to: A. Allow resident # 1 the 30 day probationary period to demonstrate her ability to care for her cat, after her return from the hospital; as documented in the facility policy. This failure by the facility could affect any of the facilities 3 residents that had pets. The findings included: Record review of the face sheet dated 1/16/13, for resident # 1 documented she was an [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. In a observation of resident # 1 on 3/21/13 at 12:25 pm, resident # 1 was in her wheel chair in her room, eating her lunch, resident # 1 was feeding herself. Resident # 1 had the cat food and water bowl set up in her room and the litter box was set up in her bathroom. The cat supplies were clean. No odors were observed in the room. In an interview on 3/21/13 at 12:25 pm resident # 1 said the Administrator and DON would not let her have her cat back. The cat had resided in the facility with her since her admission in 2009. Resident # 1 said she knew she was old but she had the right to die with her cat with her, she had some friends but no one else close to her. Resident # 1 said she went to the hospital recently and the facility had her friend take her cat home. When resident # 1 returned from the hospital the facility would not let her have the cat back except to visit for a short time. Resident # 1 said she had always taken care of the feeding and watering of the cat and she sifted out the litter box. Resident # 1 said the housekeeper had always dumped the litter box but the Administrator and DON(Director of Nursing) would not let the housekeeper do it anymore. Resident # 1 said she had always kept her door closed to keep the cat in her room and the cat had never hurt anyone. Resident # 1 said she had not been given the opportunity to try to empty the litter box. Record review of the grievance log for 2013 did not reveal any concerns related to odors or resident pets. In a telephone interview on 3/21/13 at 1:45 pm resident # 1 ' s friend said resident # 1 had kept the cat for years. When resident # 1 went to the hospital the hospital last week the facility called her to come and get the cat. They said I had to come get it right then and they would not allow me to bring it back. The DON said resident # 1 could not keep the cat. The cat was very good to keep and not a problem. Resident # 1 was very upset. Resident # 1 told her yesterday to not bring the cat to visit because the Administrator and the DON had talked with her about the cat and she had become so upset she had vomited and did not feel well. Resident # 1 did occasionally vomit because of health conditions. In an interview on 3/21/13 at 1:50 pm the DON said resident # 1 had went to the hospital with a possible [MEDICAL CONDITION] last week. This was when the cat was sent home and when the 2 residents with dogs were not able to keep them, there would not be any more pets in the facility. In an interview on 3/21/13 at 1:50 pm the Administrator said the policy on pets said the resident was not able to keep a pet unless the resident was able to care for them self and the pet and the policy was being changed to no pets in the facility. The decision that resident # 1 was not able to keep her cat any longer was an arbitrary decision. The Administrator said the housekeeper would not be emptying the litterbox for resident # 1 anymore. In an interview on 3/21/13 at 2:05 pm Housekeeper " A " said resident he had been emptying the letter box when resident # 1 had not been able to do it. House keeper "A" said he could not empty the litter box anymore. In an interview on 3/21/13 at 2:08 pm a hole was observed in the social services office window screen and a dog was observed coming into the facility from outside, through the hole in the screen. In an interview on 3/21/13 at 2:19 pm the Social Worker said she did not know how the hole got in the screen but the dog just used it. In an interview on 3/21/13 at 2:22 pm the Administrator said he did not know about the hole in the screen. The Administrator said the dog was his dog. Clinical record review for resident # 1 did not reveal any assessments for resident # 1 related to ability to provide for the cat. Record review of facility ' s undated policy documented in item # 9 the if a resident left the facility for a change in condition, the animal would not be allowed back in the facility until the resident arrived back in the facility and a 30 day probationary period would resume when the resident arrived back to the facility. This probationary period included the resident being able to take the animal outside for bathroom use and independently clean the litter box. In an interview on 3/21/13 at 2:28 pm the DON said the careplan dated 10/15/12 did address resident # 1 having a cat. The DON was not aware of any assessments having been done related to resident # 1 being able to care for the cat. In an interview on 3/21/13 at 2:30 pm resident # 1 was interviewed with the Social Worker present. Resident # 1 said the Administrator had allowed the housekeeper to change the cat litter until she returned from the hospital. Resident # 1 said she could take care of the cat and she could learn to empty the litter box, she had learned how to go to the toilet and how to manager her catheter, she felt she could manage the litter box. In a telephone interview on 3/21/13 at 2:45 pm resident # 1 ' s son said he was aware of the situation involving the cat and he was not aware of any assessments having been done. He was not given any specific details and he did not feel keeping the cat was detrimental at this point. Resident # 1's son said he felt resident # 1 having the cat would be good for her. Resident # 1 got a great deal of enjoyment from keeping her cat. Resident # 1 ' s son said he felt the policy led to eventual disappointment for the resident. Resident # 1 ' s son said the Administrator told him, if the cat was not removed a 30 day notice to move would be given. Interview with the DON on 3/21/13 at 1:50 pm revealed 2 other residents had pets in the facility.